Use of staging in intermediate-risk prostate cancer: A real-world data analysis.

[OBJECTIVE] Current EAU guidelines provide only a weak recommendation for staging (computed tomography [CT], magnetic resonance imaging [MRI], bone scan, or prostate-specific membrane antigen [PSMA] positron emission tomography [PET]/CT) in selected intermediate-risk prostate cancer (irPCa) patients. However, data on the real-world application of staging in this group are limited. We aimed to assess the use of various imaging modalities for distant staging in irPCa patients scheduled for radical prostatectomy (RP).

[MATERIAL AND METHODS] We identified irPCa patients from a high-volume institutional database who underwent primary RP between 2015 and 2021. The use of different staging modalities was assessed, with stratification according to NCCN criteria into favorable and unfavorable intermediate-risk groups. Annual trends were analyzed.

[RESULTS] Among 9,512 irPCa patients, 37.4% had favorable and 62.6% unfavorable disease. Overall, 42.0% underwent any form of staging prior to RP, with higher rates in unfavorable versus favorable disease (48.5% vs. 31%, P < 0.001). The detection rates of locoregional or metastatic disease using conventional imaging were low (0%-2.0%). For PSMA PET/CT, the rates were 5.0% and 4.3% in the favorable and unfavorable groups, respectively. Bone scans (34.7%) and abdominopelvic CT (28.0%) were most frequently used in unfavorable cases, with 20.1% undergoing both. Only 6.2% (n = 369) of unfavorable patients received PSMA PET/CT. Among favorable cases, 22.0% underwent bone scans and 17.8% abdominopelvic CT; 11.9% had both, and just 2.8% (n = 100) received PSMA PET/CT. MRI was rarely used (1.7%; 1.9% in unfavorable vs. 1.3% in favorable cases, P = 0.1). Overall staging rates remained stable during the study period (EAPC: 0.04, P = 0.9), whereas PSMA PET/CT usage significantly increased in the total cohort (EAPC: 17.9, P < 0.01) and in the unfavorable group (EAPC: 21.1, P < 0.01).

[CONCLUSIONS] Less than half of patients with unfavorable irPCa and approximately one-third of those with favorable irPCa underwent distant staging. Positive findings were rare, especially with conventional imaging. Therefore, conventional staging might be safely omitted in irPCa, while PSMA PET/CT may be considered in selected patients when staging is deemed necessary, as it provides more accurate information.